A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
“I need to make sure that the potential victim is warned."
"I need to keep the information confidential due to the client's right to privacy."
“I can only discuss the client's threats with a court order."
"I should verbally report this information to the psychiatrist."
The Correct Answer is A
A. "I need to make sure that the potential victim is warned."
Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.
B. "I need to keep the information confidential due to the client's right to privacy."
Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.
C. "I can only discuss the client's threats with a court order."
Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.
D. "I should verbally report this information to the psychiatrist."
Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Schedule regular weigh-in times: Monitoring the client's weight on a regular schedule is important in managing anorexia nervosa. It helps track progress and any potential complications related to weight loss.
B. Allow the client to eat at any time: For individuals with anorexia nervosa, there is typically a structured meal plan that is carefully monitored by healthcare professionals. Allowing the client to eat at any time might disrupt the planned nutritional intake.
C. Provide privacy when friends visit: Privacy is important, but it should be balanced with ensuring the client's safety and adherence to the treatment plan. Visitors might need to be supervised to prevent any behaviors that could exacerbate the disorder.
D. Compliment the client for weight gain: While support and encouragement are important, complimenting a client for weight gain might inadvertently reinforce a focus on body image and reinforce disordered eating behavior. It's crucial to provide positive reinforcement for adherence to the treatment plan and progress in recovery, rather than emphasizing weight changes.
Correct Answer is ["2"]
Explanation
The nurse is preparing to administer benztropine 2 mg IM every 12 hours. The concentration of the available benztropine is 1 mg/mL.
To calculate the volume (mL) of the medication needed for the prescribed dose, you can use the formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = 2 mg / 1 mg/mL = 2 mL
So, the nurse should administer 2 mL of benztropine 1 mg/mL for each dose. Since we're looking for a whole number, we round to the nearest whole number, which is 2 mL.
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